Introduction: It is unknown whether the treatment disparity observed between young and elderly women extends to the management of positive margins after initial lumpectomy. The primary aim was to evaluate the management of positive margins after initial lumpectomy in elderly women. Methods: Women ≥50 y who underwent lumpectomy for stage I–III tumors were identified. Tumor and treatment characteristics were collected across two subgroups: young (50–69 y) and elderly (≥70 y). Univariate comparisons were done using chi-square and Wilcoxon Rank Sum test. A multivariable logistic regression was used to evaluate factors associated with reoperation. Incidence of overall recurrence was compared between young and elderly women by plotting the cumulative incidence function of overall recurrence and death without recurrence. Results: Of 1670 women identified, 29.5% were elderly. Compared to young women, tumors in elderly patients were more frequently invasive lobular carcinoma, larger, low grade and lymphovascular negative. Positive margins were less common in elderly than young women (10.8% versus 16.2%, unadjusted OR 0.60, 95% CI 0.42–0.86). Compared to young women, elderly women were less likely to undergo reoperation (84.9% versus 100%, p < 0.001), adjuvant chemotherapy (5.7% versus 46.6%, p < 0.0001), and adjuvant radiation therapy (69.8% versus 83.9%, p = 0.04). Five-year disease free survival (DFS) was similar between age groups (86% versus 86%, p = 0.8). Conclusions: Elderly women with positive margins after initial lumpectomy were treated differently than younger women as shown by a lower rate of reoperation and adjuvant radiation therapy. Despite these treatment variations there was no impact on overall recurrence and DFS.